Current rates of contact lens dropout are estimated to be 16 to 34% per year.1,2 By the age of 45, the majority of contact lens wearers have dropped out, leaving just 29% of this age group utilizing lenses.3,4 Across all populations, patients report discomfort and dryness as the top reasons for abandoning their contacts.4,5
It is well established that dry eye disease (DED) and contact lens complications can often be related, with each contributing to the other.5 Contact lenses are known to exacerbate existing homeostatic imbalance of the ocular surface, making patients exhibiting Demodex blepharitis, meibomian gland dysfunction, and quick tear film evaporation more prone to drop out.5
The solution is an accurate assessment and ongoing optimization of the ocular surface prior to prescribing lenses and throughout the lens journey. As a clinician, educator, dry eye/contact lens aficionado, and partner with Premier Vision Group in Northwest Ohio, Dr. Brujic confronts all of the usual culprits that contribute to DED, including environmental factors and extensive screentime on digital devices. In response, he has developed a proven protocol to assess contact lens wearers with DED.
3 types of contact lens wearers
Prior to performing a thorough workup, Dr. Brujic finds it helpful to identify the type of contact lens wearer being examined.
He places contact lens wearers into three buckets:
- Refractive: Patients seeking an alternative to glasses, who either do not want or are not good candidates for refractive surgery.
- Specialty: Individuals who cannot achieve appropriate vision from standard vision correction options.
- Proactive fits: People with conditions that will benefit from treatment with lenses:
- Patients with mild to moderate epithelial basement membrane dystrophy (EBMD) not interested in phototherapeutic keratectomy (PTK) or corneal debridements do well with higher modulus silicone hydrogel lenses.
- Individuals with more moderate to severe dry eye with recalcitrant ocular surface staining may benefit from scleral shells, soft lenses as bandages, or lenses leveraged as a “shell” for dry amniotic membranes.
When encountering a soft contact lens wearer approaching presbyopic years who is starting to notice visual fluctuations and less comfort, the first approach is to try a newer lens modality or material. However, once the technology has been maxed out, it is imperative to recognize the role of the ocular surface.
Conducting a comprehensive dry eye workup
Once the contact lens category has been determined, Dr. Brujic proceeds with a thorough dry eye workup using a simplified diagnostic algorithm.
This logical approach involves an interview and then an examination that starts at the front and moves to the posterior surface. “We do the assessment first, then we take lenses off and do the refraction. Next, we do the anterior segment evaluation without the lens on,” Dr. Brujic stated.
On the subject of assessment, Dr. Dierker added, “I think what is so critical is that the process is reproducible, quick, and done every time. As we have new therapeutic tools, you can refine what you're doing for those patients, but you have a process and commit to it.”
Elements involved in each evaluation include:
- Standard Patient Evaluation of Eye Dryness (SPEED) questionnaire: Assigns a number to the actual symptoms that the patient is experiencing.
- History: Achieves ocular and medical background of the patient.
- Exam: Comprehensive examination to check for Demodex overpopulation and meibum quality.
- InflammaDry MMP-9: Detects elevated levels of MMP-9, an inflammatory marker that is consistently elevated in the tears of patients with dry eye disease.6
- Fluorescein dye: Highlights any defects of the corneal epithelium by filling in the gaps of missing cells, allowing the clinician to grade the ocular surface damage.7
- Corneal esthesiometry: Utilizes the BRILL esthesiometer to measure corneal sensation and assess the status of corneal innervation.8
- Proparacaine challenge test: Establishes the origin of pain to differentiate central from peripheral sources of pain.9
3 critical questions for DED
In addition to the standard SPEED questionnaire and history, every patient is asked to provide two different rankings of their symptoms on a scale of 0 to 10, with 0 being the least comfortable and 10 being the most comfortable. First, he inquires about the comfort level of their lenses at the 5- to 10-minute mark after insertion. Then, using that same scale, he asks about the comfort level at the end of the day.
According to Dr. Brujic, “Most people will say 8, 9, or 10 after the lenses have settled on their eyes. However, a lot of times, at the end of the day, there's this precipitous drop. That's where we start thinking about new technologies and lenses and also what ocular surface issues may be compromising that patient's ability to wear those lenses.”
Dr. Brujic also inquires about the patient’s visual symptoms in and out of lenses.
Exam basics
To identify Demodex overpopulation, using magnification, Dr. Brujic has patients look down as he pulls the upper eyelid up to ensure collarettes are not present at the base of the lashes.
To gauge the meibum quality, he advises pressing gently along the eyelid margin to release the substance from the meibomian gland orifices. Healthy meibum should have the makeup of olive oil.
Instill fluorescein dye: every patient, every time
On each patient and at every encounter, Dr. Brujic instills fluorescein. He stated, “We put fluorescein on the eye because, as you're well aware, there are several things that are invisible with just a standard white light assessment that can be seen with a cobalt blue light and a Wrattan #12 filter.”
Note: In Dr. Brujic’s practice, the dry eye workup is virtually identical for all patients.
Optimizing the ocular surface to maximize comfort
Once it is confirmed that discomfort subsequent to DED is contributing to contact lens complications, it is imperative to treat the ocular surface. Of course, treatments may include pharmaceuticals, at-home treatments, and in-office procedures.
In patients with Demodex infestation and blepharitis, one of the easiest and most effective ways to do so is with microblepharoexfoliation. A 2019 Australian trial (randomized, interventional, unmasked, crossover) uncovered that, after a single, in-office microblepharoexfoliation treatment, both tear film and eyelid signs improved, leading to alleviated contact lens discomfort.10
Lotilaner 0.25% can now be utilized for these patients to rid the lid margin of Demodex overpopulation. For individuals with low inflammatory readings whose meibum and lid margins are healthy, Dr. Brujic also utilizes sodium hyaluronate gel placed in the lower puncta to retain the tears on the surface. However, if inflammation levels are elevated, immunomodulatory agents (i.e., lifitegrast and cyclosporines) are implemented.
Meibomian gland issues can be addressed through:
- Pharmaceutical options (i.e., perfluorohexyl octane)
- Gland expression
- LipiFlow Thermal Pulsation
- Intense pulsed light (IPL)
Final thoughts
To avoid contact lens dropout and ensure patients are living in their best visual world with minimal discomfort, it is crucial to have a proven protocol for performing a dry eye workup on contact lens wearers.
In the words of Dr. Dierker, “It's all about giving the patient the vision they want; we have very little chance of doing that successfully if we ignore the ocular surface in these patients. If we can identify the comorbidities prior to making a recommendation for technology, they have a much better chance for success.”
